From 2002 till 2010, the members of the International Network Health Policy & Reform met once a year for a continuing review of the goals, tools, and priorities of their work and to discuss current health policy issues.
"Planning and Implementing Change in Health Care" was the cut-across theme of this year's Annual Symposium. Addressing a pressing challenge in health policy research everywhere, sessions centered around how to achieve change in health care, looking at workforce, services and infrastructure planning, as well as the politics of policy and implementation of change.
Planning and provider shortages - international approaches and solutions Healthcare planning and its role to initiate, implement or respond to change raises the question of what can be left to markets and competition, and what should be regulated or planned. Participants discussed whether planning was the problem or the solution, and found that each country addresses health care planning in different ways.
May Tsung Mey-Cheng framed the inaugurative session on health workforce planning along five main observations: 1) a growing global shortage of
working-age population, driven mainly by a rising old-age dependency ratio, 2) an inefficient assignment of tasks across health workers with different levels of education and training, 3) an
inefficient mix of physicians types, 4) a geographically inequitable allocation of the health workforce, and 5) a socially inequitable allocation of the health workforce within countries.
Participants illustrated these challenges and shortfalls in practice.
Toni Ashton showed that New Zealand and Australia are both implementing strategies to increase the overall and regional supply of physicians and other health workers - however, provider allocation remains geographically and technically inefficient. Provider organizations might play an important role in conjuring up shortages and putting politicians under pressure.
Ryozo Matsuda presented and explained causes of and strategies against the shortage of paediatricians and obstetricians in rural areas of northern Japan.
Zeynep Or talked about the chances and challenges of introducing skill-mix approaches in France. Propositions for developing new forms of cooperation faced strong opposition from physicians as well as nurses. As a consequence, the regulatory framework remains as it used to be. Health professionals are encouraged to develop initiatives in a bottom-up process instead.
Gerard Anderson chaired a session on planning of health services and healthcare facilities. In his opeing remarks he observed that health policy seems to operate in
cycles - as market and competition approaches have been en vogue for decades, it now seems that there is a new trend back to more regulation and health planning.
Mickael Bech showed how Denmark strictly plans the allocation of hospital facilities and specialties all over the country, even against public opposition.
Maria Hofmarcher explained how Austria's regional health planning for 32 healthcare regions works: Healthcare needs are estimated considering capacity, scope and quality. Although regional planning is heading into the right direction, target volumes need to be linked to costs and quality measures, and incentives for regions to meet target provisions have to be improved still.
Moreover, guest speaker Ellen Nolte from RAND Europe presented a framework for assessing, improving and enhancing healthcare planning that uses three main criteria for healthcare planning: 1) a clear vision, concretized by goals and objectives, 2) governance, with clear roles and responsibilities, incentives and sanctions, and 3) intelligence, i.e. analysis of relevant data, continuous monitoring and measuring of progress against set objectives, and sufficient capacities to carry out these tasks.
Bargaining for change in health care and the crux of implementation
Participants discussed what happens to original reform ideas during the legislative process, drivers and barriers decision makers have to keep in mind, and how to implement change in the healthcare system.
Opening a session on bargaining change in the political arena, Sophia Schlette shared her impression as an observer of U.S. health reform since 2009. While passage of the
health reform law in March was a good thing, leading to a historic expansion of coverage and access, it is only a first step toward better and more efficient health care for all U.S. citizens, she
said. Reflecting on the Dutch, Swiss and German experiences since the 80s and 90s, she highlighted three common threads in health reform processes: 1) Reforms take time, often decades, 2) reforms are
incremental and path dependent, i.e. they evolve within the culture of a country, and 3) successful reforms are bipartisan - the consensual result of multiparty bargaining in politics and
society. In his detailed analysis of US healthcare reform
Uwe Reinhardt provided a deep look into the 'sausage factory', a popular metaphor used to describe the health reform process: once it starts production, nobody knows what the sausages coming out of it actually consist of. He depicted the American exceptionalism in health care: unique challenges(like unsustainable national health spending, pricing the middle class out of health care, the growing number of uninsured, problems in the non-group market), and unique features in the political culture of this country, such as its social ethics and a deeply rooted mistrust in anything government resulting in weak governance. Reinhardt presented the health-reform bill that became law together with a rather pessimistic assessment of the further development on costs and financing.
Hans Maarse spoke about the politics of the Dutch health insurance market reform. Competition in health insurance does not make much sense unless aligned with competition in health care provision, i.e. insurers becoming purchasers, he said. However, insurers continue to focus more on prices than on quality of care. And combining competition (freedom) with macro budgets (control) still seems to be a task of squaring the circle.
Luca Crivelli followed with an analysis of the impact of consensual decision-making and direct democracy on Swiss healthcare reforms. He argued that the reform process in Switzerland is usually slow and full of conflicts of interest. While popular ballots, for example, are a radical form of "voice", they tend to strengthen status quo and rarely result in a change of political direction: Of 12 popular ballots on reforms in the health insurance sector held between 1974 and 2008,, all proposals but two have been rejected in these ballots.
Lim Meng Kin concluded the session with a presentation on Singapore where healthcare reforms are led by pragmatism and endorsed by a sense of public trust and what Lim described as Asian values: the community comes first, not the individual. He stated that Singapore has found the right balance between individual and state responsibility: In Singapore, health care financing is a shared responsibility via taxes, medical savings accounts and a catastrophic insurance. The interventionist approach of politics in Singapore ('Solve problems before they arise.') has lead to a decline in government share in Singaporean health care expenditure.
In the symposium's final session on drivers and barriers of implementing change, Marion Haas set the stage discussing findings from ongoing research
about the difficulties with disinvestment strategies. Active disinvestments, such as a partial or complete withdrawal of resources from technologies that deliver low or no health gain for their cost,
are hard to conduct since benefits or savings may not be realised immediately (or ever) and losses may outweigh benefits. The impetus for disinvestment, she concluded, can only come from changing
Ain Aaviksoo analyzed the blockades of moving forward with the national health-IT system in Estonia, despite high acceptance of health IT by patients, providers and politics: Incentives are often not aligned, and costs and benefits of the electronic health record system are unequally distributed: while 65 percent of the costs are borne by providers and only 35 percent by society, society benefits the most.
Revital Gross's presentation was about using patient experiences to improve the health care system in Israel. Results of patient survey are broadly disseminated and discussed by patient associations, sickness funds, providers, the media and parliament. On top, survey results often have an impact on the macro level of health politics (changing legislature) as well as on the micro level of health service delivery.
Participants of the 8th Annual Symposium in Krakow, Poland
What works and what doesn't in health human resource policy? How can we improve service delivery for the chronically ill? How can we support evidence-informed health policymaking? These were some of the questions discussed by participants at the 8th Annual Symposium of the International Network Health Policy and Reform, which took place in Krakow, Poland, from July 1-4, 2009. The overall motto of the Symposium was "Identifying good practice for evidence-informed health policy making".
Bridging the gap between research and policy
Special guest speaker was John Lavis, Professor and Canada Research Chair in Knowledge Transfer and Exchange at McMaster University, Ontario. John Lavis emphasized that stronger interactions between researchers and policymakers are essential to support research use by policymakers. Foundations and other third parties can promote this exchange by acting as knowledge brokers. Another important aspect according to Lavis is to facilitate the retrieval of research evidence for example through the provision of systematic reviews and review-derived products such as training workshops for policymakers and so-called evidence briefs that contain key messages. John Lavis and his colleagues at McMaster University actively contribute towards this goal: They set up a database (www.researchtopolicy.ca/Search/Reviews.aspx) which contains more than 800 systematic reviews about questions of health system governance, financing and delivery arrangements.
Looking for good practice: Human resources and new delivery systems
Day one of the network's Symposium was all about good practice examples in human resource policy and service delivery. Peter Groenewegen, Director of the Netherlands Institute for Health Services Research (NIVEL) and guest speaker at this year's network meeting, reported on the successful introduction of new professions and the promotion of skill mix in the Netherlands to improve the quality of care and ameliorate the problem of physician shortages. Evaluation results show that new professions such as nurse practitioners spend more time and provide better coordinated care for patients. Physicians are able to concentrate on complex medical tasks, and costs of care slightly decreased. Elena Conis from Emory University, Atlanta, took a critical look at U.S. states' efforts to improve working conditions and thus increase recruitment and retention of nurses by implementing nurse staffing ratios. Nurse staffing ratios seem to work in that they increase nurses' satisfaction and improve patient care outcomes. However, it is still unclear if this trend continues and, in the long term, can help solve the problem of nurse shortages nationwide - states that implemented nurse staffing ratios are drawing nurses from neighboring states and from Canada, which aggravates problems there.
Margaret MacAdam from the Canadian Policy Research Networks presented results from a study that looked into progress in implementing integrated care systems for people with chronic conditions in Canada. While many Canadian provinces have already introduced essential features for better integration such as single or coordinated entry systems, standardized, system level assessment procedures, system-level case management and procedures to involve clients and families, most provinces are still lacking shared electronic health information systems and effective decision tools. One province that is far ahead of other provinces is Quebec with its PRISMA project. PRISMA - the Program of Research to Integrate the Services for the Maintenance of Autonomy - brings primary care, acute, rehab and community-based care together in a shared collaborative governance model. Evaluation results show that patients treated within the PRISMA project have fewer visits to Emergency Rooms and fewer hospitalizations, functional decline is lower for those enrolled in PRISMA than for those treated in the regular health care system, and PRISMA better meets the needs of its clients and increases satisfaction.
Comparative effectiveness in policy decisions: One goal, different strategies
Day two of the symposium was dedicated to evidence. Participants looked at comparative effectiveness programs in four countries and discussed questions such as who conducts such research and who pays for it? Are the decisions made in such institutes mandatory for payers and providers or 'just' advisory? How transparent is the decision-making process? The discussion showed that each country's comparative effectiveness program has its unique aspects. Israel for example emphasizes close involvement of stakeholder groups and transparency. The group that evaluates the costs and benefits of new drugs and procedures consists of a broad range of actors ranging from economists, health professionals, payers, manufacturers to patient representatives. Decisions about inclusion of new elements into the benefit basket have to be taken unanimously. Evaluation results are made available to the public through media. Revital Gross from the Myers-JDC-Brookdale Institute in Jerusalem noted that this process forms the basis for broad acceptance of comparative effectiveness decisions and trust in the actions of policy and decision makers, especially in times of limited financial resources.
All presentations of the 8th Annual Symposium are available for download on this website (see boxes on the right).
"The happiest person is he who thinks the most interesting thoughts". With these words by William Lyon Phelps, Adam Oliver from the London School of Economics aptly described the atmosphere of the 7th Annual Symposium of the International Network Health Policy and Reform. From July 2-5, 2008, the network partners from 20 countries met in Ljubljana, Slovenia, to discuss recent health policy developments and ideas.
Topics discussed included the development of the health systems of Central European countries since their independence, the HealthBASKET project (which compared health services, their definition and costs across nine EU member states) as well as the effectiveness of new forms of care that are to improve coordination between providers and between care sectors. Moreover, the experts looked into how care for individuals with mental illnesses can be improved - an issue that slowly rises to the top of the agenda of health policy makers around the globe. Good practice examples came for example from Australia and Canada, where efforts are undertaken to better educate citizens about mental illnesses, symptoms and treatment options. With comprehensive programs they aim to raise public awareness and to increase acceptance for mental diseases among the general population. Moreover, improving access to (community-based) services and decreasing the stigma associated with mental disorders are stated goals of the national plans developed in these countries.
In the last session, the question of how health care resources can be equitably allocated sparked a lively discussion among the participants. How do countries cope with the demand for free and equal access to care on the one hand, and the need to rationalize services due to scarce resources on the other hand? Is economic evaluation the answer? How can values and preferences of different societal groups be incorporated into economic evaluation? Can other / additional principles such as the fair innings argument or the rule of rescue guide decision-making? While economic evaluation of interventions plays a major role in some countries such as the UK, it receives less weight in others: In the Israeli commission that decides about the inclusion of services into the benefit basket, only one out of 13 members is a health economists. The others are bio-ethicists, doctors, sociologists, etc.
As a special guest at this year's symposium the network was proud to welcome the Slovenian Minister of Health Zofija Mazei Kukovic. In her opening speech the minister emphasized the usefulness of international knowlegde exchange in the field of health care. She underlined that despite systemic differences between countries and regions, health systems world wide face similar challenges. Tools such as the Health Policy Monitor are therefore extremely valuable in identifying best practices and workable solutions.
Which values is health care policy based on? What can we learn from other countries' experiences? How can fragmentation of care delivery systems - a problem shared by many countries - be
overcome? These were the questions addressed by the experts of the International Network Health Policy and Reform during their sixth annual symposium on 4-7
July 2007 in Berlin. Not only network partners from 20 countries took part in this "study tour around the world - Comparing challenges, solutions and values in health care politics"
but also guests like Rudolf Klein, Professor at the London School of Economics, and Uwe Reinhardt, Professor at Princeton University ...
The idea to learn about and from other countries' health care systems is one of the central goals and means of the network and startet off this year's discussion. Partners from New Zealand, Israel and the US reported results from their research visits in other network countries. Apart from comparing systemic factors like choice for patients, co-payments and waiting times, the experts also ventured to give possible explanations for the perceived differences.
A second topic discussed was how to enhance coordination and continutity of care and thereby optimizing care especially for chronically ill patients. While electronic heath records or disease management programs promise to improve quality and efficiency of care, a recent study by the OECD implies that problems resulting from a lack of coordination - especially between medical care and long term care - still exist in many countries. In this respect, providing adequate care for patients suffering from a plurality of chronic conditions at the same time will be one of the most important future challenges.
In the last session "Values in health care", discussion focused on terms like solidarity, personal responsibility, access to quality care, equity and
efficiency. Can these be termed "valus" in health care? Or are some of them merely "hurrah-words" which, as Rudolf Klein argued provocatively, are supposed to generate a positive
feeling while lacking substance? What do these ideas mean in a political context? Are they valid from an international, maybe even global perspective (e.g. UN charter and universal
declaration of human rights)? Or are there - as Professor Lim Meng Kim from Singapore demonstrated - differing values in eastern and western cultures?
Insights won and questions raised at this year's meeting will certainly accompany the International Network Helath Policy and Reform in its future work.
From 14-17 June 2006, health policy experts from all 20 partner institutions of the network discussed current health policy issues at the National Research and Development Centre for
Welfare and Health (STAKES) in Helsinki, Finland. Topics on the conference agenda included globalization, policy analysis, and ICT in health care.
Kimmo Leppo from the Finnish Ministry of Social Affairs and Health opened the meeting with a discussion of national health policy in the context of Europeanization, globalization and decentralization - a very topical issue for the Finnish government since the country will hold the EU Presidency during the second half of 2006. The government recognizes the potentials that globalization and Europeanization of health care can create but also sees problems and pressures (e.g. legal uncertainty due to the EU Services Directive, etc.). Furthermore, Leppo described current public sector reforms and efforts to recentralize powers in health care (e.g. establishment of national quality guidelines, earmarking of funds for certain health services) after a long period of decentralization and devolution of responsibilities to municipalities. The experts further debated the creeping influence of supranational organizations such as WTO, GATS, etc. on national health policy, particularly. Case studies from Australia, Taiwan and Thailand illustrated how free trade agreements exert pressure on countries to open their markets for, amongst others, pharmaceutical products, interfering with national policies to set drug prices in the interest of securing access to and fair financing of health care services. On the other hand, to support member countries in working toward a better coordination of care, the OECD is developing a framework to assess the efficiency of health care systems by measuring its readiness and flexibility to cope with this cross-country challenge. Presenters of this session were Meri Koisuvalu, May Tsung-mei Cheng, Marion Haas and Maria Hofmarcher.
Tom McIntosh, Director Health Network, Canadian Policy Research Networks, spoke about shifts in health policy direction under the newly elected Conservative Party in Canada. The new government expressed its commitment to care guarantees for key services but remains vague on how it plans to achieve this goal. It is reluctant to take on a stronger leadership role which would be necessary to achieve consensus with the 17 provinces and territories that are responsible for the planning and financing of health care services in Canada. Cezary Wlodarczyk, Jagiellonian University, Krakow, reported on the unwillingness of political parties in Poland to take over accountability for policy making and the consequences for health care reform. Another item on the agenda was the health insurance reform in the Netherlands that came into force at the beginning of 2006, commented by Hans Maarse from Maastricht University.
In the last session, participants discussed the introduction of information and communications technologies (ICT) in health systems and their impact on effectiveness, efficiency, and quality of care. Jörg Sembritzki from the Centre for Telematics in Health Care in Krefeld, Germany, pointed out that a major challenge for policy makers in many countries is to build up trust and acceptance among users and the public for new ICTs. Wrapping up the meeting, the participants concluded that interesting next steps for the research network were to identify health care reform trends, and to analyze how the introduction of more competition into health care systems will affect health care provision and quality.
Hosted by the Research Centre for Economy and Health (CRES), Universitat Pompeu Fabra, and the IESE Business
School, University of Navarra, the Spanish context of health system and public sector reform set
the frame for engaged debates.
Guillem López, CRES, gave an overview of the decentralization process in Spain and the devolution of health care regulatory competencies to the autonomous regions, followed by a business case of a public-private partnership model in a Spanish region, where a private health insurance company holds a long-term concession to organize and provide comprehensive health care for a population fo 150.000 inhabitants under tight public control. Martin Gaynor from Pittsburgh/Pennsylvania spoke on competition in health care markets, provoking an academics debate about evidence vs. values in health economics, or positive vs. normative economics. Alan Maynard, University of York, presented findings from an international comparison of the public-private mix for health care and on the importance of getting financial incentives right. Toni Ashton, University of Auckland, New Zealand, reported on recent developments on primary care, and Michael Appel from the University of Southern Denmark reviewed the history of reforms, or lack of them in his country. Representatives from the new network countries commented upon this. Tit Albreht spoke about the recent shift in health policy direction towards more market-oriented solutions under the newly elected center-right government in Slovenia, a change that may leave some nicely developed population health approaches uncertain. Ruta Kruuda from PRAXIS, Tallinn/Estonia concluded that health policy topics concur - the need for discussions and search for solutions given the widespread commonality across industrialized nations is well acknowledged today in the researchers and the policymakers worlds. Uwe Reinhardt, Princeton University, wrapped it all up reminding everyone of the "Good things governments did". His point was that a lot of the conceptual and innovative work in the field of managed care, payment incentives, quality management etc. had been developed, with public funding, by public research institutions and the larger public insurance schemes in the US, before they were taken up, copied and adapted in the market.
The third network meeting took place in Bertelsmann's new conference venue in the heart of Berlin.
Kicked off by a provocative statement from Alan Maynard, Department of Health Sciences, University of York on the do's and don't of health care reform, participants discussed health care financing options, the challenges of aging for long-term care and health care services, and the role of prevention in leading health lives.
Other keynote speakers included Franz Knieps, Head, department of health insurance financing and long-term care at the German Federal Ministry of Health and Social Security, Julien Forder, a policy analyst at the UK Department of Health on long-term care issues, and Uwe E. Reinhardt, Princeton University, on state-of-the-art prevention research projects in the US.